Nipple Reconstruction
Frank DellaCroce, M.D., F.A.C.S.
September 21, 2017

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Dr. Frank DellaCroce, or "Dr. D" as he has come to be known, is a founding partner of the Center for Restorative Breast Surgery and St. Charles Surgical Hospital in New Orleans. Board-certified in plastic surgery, Dr. D has performed thousands of reconstructive procedures, both for women diagnosed with breast cancer and women at high risk of the disease who choose to have prophylactic breast removal. He is a fellow of the American College of Surgeons and a member of numerous professional societies, including the American Society of Plastic and Reconstructive Surgery, the American Society for Reconstructive Microsurgery, and the World Society for Reconstructive Microsurgery. He also has been named one of the “Best Doctors in America.”

Listen to the podcast to hear Dr. D discuss:

  • the benefits and risks of nipple reconstruction
  • the timing of nipple reconstruction
  • how nipple reconstruction has evolved over the years
  • how long the procedure takes and what recovery is like

Running time: 18:06

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Show Full Transcript

Jamie DePolo: This podcast is made possible by the generous support of the Center for Restorative Breast Surgery in New Orleans.

Hello, everyone. I’m Jamie DePolo, the senior editor here at Breastcancer.org. Welcome to this edition of our podcast. Our guest today is Dr. Frank DellaCroce, or Dr. D as he’s come to be known. He’s a founding partner of the Center for Restorative Breast Surgery and the St. Charles Surgical Hospital in New Orleans. Board certified in plastic surgery, Dr. D has performed thousands of reconstructive procedures both for women diagnosed with breast cancer and women at high risk of the disease who choose to have prophylactic breast removal. 

He is a fellow of the American College of Surgeons and a member of numerous professional societies, including the American Society of Plastic and Reconstructive Surgery, the American Society for Reconstructive Microsurgery, and the World Society for Reconstructive Microsurgery. He also has been named one of the best doctors in America. Today, he joins us to talk about nipple reconstruction. Dr. D, welcome to the podcast.  

Dr. Frank DellaCroce: Thank you, Jamie. It’s a pleasure and an honor to be with you today. 

Jamie DePolo: I have heard you say that nipple reconstruction completes the restoration of beauty and wholeness. Can you talk about how nipple reconstruction and nipple tattooing has evolved over the years? 

Dr. Frank DellaCroce: Nipple reconstruction is often underestimated in terms of the impact it has on the final overall result in breast reconstruction. When done properly, and when done with attention to detail, it has the transformational effect of moving the breast mound and the soft tissue restoration to a place where the eye then appreciates it as a breast, as a natural component of the woman’s overall body. And so the attention to getting better at doing what we do has been something that we’ve really focused in on in the last several years. 

The advancements have come really in two primary ways. One is the plastic surgeon makes an effort to recreate a nipple that has some physicality and some modest natural component without overdoing it and creating something that doesn’t have a potential to heal properly. The second major, and perhaps even more interesting, evolution has been in the development of pigmentation techniques that allow for a nipple reconstruction to be complemented with visual reality in terms of proper hues and depth, recreation with visual shading and variations in technique. And that comes on the tattooing, or pigment application, side.  

So when those two things were married together, and the nipple hasn’t been preserved with mastectomy, we can re-create a result that is complementary to the overall breast reconstruction and a very beautiful and convincing finishing touch. 

Jamie DePolo: Are all women who have mastectomy without nipple preservation, are they all candidates for nipple reconstruction? Would there be any reason why somebody wouldn’t have it?  

Dr. Frank DellaCroce: There’s no hard and fast rule in terms of one person being a candidate or not for nipple reconstruction. The only thing that can impede the success or put someone at risk for a problem with nipple reconstruction is if their skin has been overly thinned with the mastectomy or with expansion and stretching from an underlying implant. 

Those are relatively rare scenarios, but when that happens, nipple reconstruction has the capacity to produce a situation that either A) doesn’t heal well or B) that flattens out and doesn’t produce any sort of physicality. And we even have scenarios once in a great while where the skin is so thin that the pigment won’t take properly. But those are exceptions to the rule. Otherwise, all women who’ve had a mastectomy without nipple preservation would be candidates for nipple reconstruction. 

Jamie DePolo: If they want it. I know there are some women who choose not to have it for a variety of reasons, but there isn’t any medical reason that — or I should say it’s rare that there’s a medical reason that somebody couldn’t have it.  

Dr. Frank DellaCroce: Right. Exactly correct. 

Jamie DePolo: What are the different ways that you use to create a nipple? Are there just a couple standard ways, or are there a variety of options depending on the person and the type of mastectomy and things like that?  

Dr. Frank DellaCroce: As I mentioned earlier, there’s two major sides to nipple restoration. One of them is the creation of some physical dimension, and that is the role of the plastic surgeon, and the other is the application of coloration and pigment.  

With respect to different techniques that are used to recreate the physicality, to recreate the fleshy prominence, they’re really all variations on a similar theme. They are basically an exercise that allows us to elevate small leaflets of skin and bring them around — I usually bring up the analogy of Japanese paper-folding, origami — where we bring a flat, a planar surface of skin into a folded and wrapped element that has some dimensions and physicality. And tiny sutures are used to close that area in. 

Once in a great while, if someone has a contralateral, or opposing, nipple on the other side that’s over-developed, they might like a nipple reduction on their un-operated breast. We can use what’s called a nipple-sharing technique, where we take a small portion of the other side nipple and bring it over and apply it as a graft on the newly reconstructed breast. That’s used relatively rarely, but once in a great while we’ll have someone who fits into a proper candidacy for that surgical approach. 

And then the pigmentation, as I mentioned, is the other part of the overall art. 

Jamie DePolo: In your experience, why would a woman choose, say, nipple reconstruction with the actual surgery where there’s a physical prominence to the nipple versus just shading and tattooing? 

Dr. Frank DellaCroce: Personal preference, 100%. We basically give our clients the information that allows them to decide what their preferences are and then let them be the boss, let them tell us what they would prefer. Someone who wants a surgically created nipple is someone who would like to be able to look down and see some dimension in the newly reconstructed nipple, or someone who would like the opportunity for a very subtle show through a thin garment, or someone who likes the palpability of a physical presence there. 

Women who would choose 3D nipple application with just tattooing alone are those that prefer a smooth look, that would rather not have any physicality or projection to the newly reconstructed nipple, someone who doesn’t want to have to worry for shows-through in a thin garment.  

One of the questions often is do we have any control over the size and the prominence and the projection of a nipple that might be reconstructed surgically, and we do. We do have some control over that. As a general rule, a physically reconstructed nipple tends to be relatively modest in terms of its size and projection. They tend to be softer and more compressible than a natural nipple would be. 

And so once we sort of talk through all those moving parts, we give the client, or the woman who we’re taking care of, the opportunity to direct us in terms of their preferences. 

Jamie DePolo: What is the biggest advancement in the last few years in this area? It seems like that’s where a lot of changes have been happening, because in the past, I know nipple reconstruction wasn’t really a big deal, and now it seems like, as you said, it’s kind of the finishing touch, and there are lots of choices now.  

Dr. Frank DellaCroce: As I mentioned earlier, the surgical side of it is really all variations on longstanding themes. Attention to being careful with respect to the set-up, to provide a palette of skin that’s healthy and fit to produce a nipple reconstruction. That’s some of the effort that’s gone in as skin-sparing, skin-preserving, even areolar-preserving mastectomy has continued to evolve for the woman who’s otherwise not a candidate for nipple-preservation proper. The biggest changes beyond that, however, I must say, have been in the area of micropigmentation, in the area of re-application of color to the newly reconstructed nipple. 

You know, years ago, that was a bit of an afterthought. It became clear with artists who applied themselves in a very intentional way on the tattooing side that if you have someone who’s an expert in that and has a real artistic eye for what coloration and depth and all the subtleties of how inks behave over time, with exposure to UV light, and the depth that they should be applied, when we introduce that into the arena of nipple reconstruction, we began to immediately see an improvement in the quality of the look and the longevity of the results with respect to the newly applied coloration. 

Jamie DePolo: When in the timeframe of breast cancer surgery and reconstruction or prophylactic surgery, whichever is happening, when is nipple reconstruction usually done? Is it at the same time as breast reconstruction? Is it later? How does that happen? 

Dr. Frank DellaCroce: We typically divide it up in an interval of time that for our practice is around 3 months. We like for the skin and for everything to be properly healed, because nipple reconstruction itself introduces a few small little incisions, and we want everything to be ready to receive that adjustment and to heal properly. So about 3 months after the original breast reconstruction or any time after that. 

It can be 6 months, 9 months, a year, 2, 3, 4. But a minimum window of 3 months to have everything healed, swelling and everything to be resolved, and for the result to settle in, in terms of its shape and position on the chest, so that we know the proper placement of the new nipple before we recreate it. 

Jamie DePolo: So a woman could even decide, say, 5 years later, “Oh, you know, I do think I’d like to have nipple reconstruction”?

Dr. Frank DellaCroce: Absolutely. Not a problem at all. 

Jamie DePolo: If a woman has tattooing first — say she waits a year after reconstruction and has tattooing, and then says, “Oh, you know, I think I would like a physical presence.” Is that still possible?  

Dr. Frank DellaCroce: It is. It’s still possible. The only caveat, the only consideration is that when the new nipple is reconstructed, it may distort the perimeter of the newly applied tattooed areola because the incisions create a little bit of tension where they’re closed, to borrow the skin for the new nipple within the center of the areola perimeter. And so they might need a little touch-up of the tattoo after the new physical nipple is recreated within the already tattooed area. 

Jamie DePolo: That’s good to know. And now you talked about using very fine sutures on the newly created nipple. Do those, then, have to be removed? Do they dissolve? How does that work? 

Dr. Frank DellaCroce: We typically use sutures that dissolve on their own. No need for stitches that need to be removed.  

Jamie DePolo: How long overall does the actual surgical procedure take, and then how long does recovery usually take? 

Dr. Frank DellaCroce: The surgical procedure takes about 10 minutes. The recovery itself is just the time it takes to heal the little incision lines. There’s no time away from work. We wouldn’t have you swimming in a pool or things of that sort for about 3 weeks, and after that you can generally do whatever your ordinary activities entail. 

Jamie DePolo: Have women talked to you as far as pain? Is there any pain? I know a lot of times in a reconstructive breast, there’s not a lot of sensation, but is there pain from the procedure at all?  

Dr. Frank DellaCroce: Sometimes the regeneration of sensory nerves into the skin is enough that a little bit of numbing medicine is necessary to do the reconstruction. I use it as a basic all the time anyway, and so the amount of pain and discomfort should be negligible to none once the little numbing medicine takes effect. As you mentioned, a lot of women who’ve had mastectomy are fairly insensate in the area central on the breast, and so it’s not uncommon for there to be little to no pain one way or the other. But I always use a little bit of numbing medicine just for insurance. 

Jamie DePolo: And so the woman is awake for the procedure? She can actually watch you doing it and make any comments, if she wanted to? 

Dr. Frank DellaCroce: Sure. We always, yeah, we always recommend — we always appreciate real-time feedback! Yeah. Sure. We do these things in the office. If we’re limiting our little adjustment that day to a nipple reconstruction, we do it in the clinic as a minor procedure. As I mentioned, about 10 minutes, and have a conversation about whatever else we’re interested in as we fix things up. 

Jamie DePolo: Now are there any risks at all to the procedure? I mean, it sounds fairly straightforward, but I figure I should ask. 

Dr. Frank DellaCroce: Fairly straightforward. Yes. You know, the risks are pretty basic. The primary one is that things don’t heal properly for one reason or another. Or if the skin is very thin, that the nipple would collapse and flatten as things heal. Beyond that, those risks in and of themselves are relatively minimal. 

Any time we make an incision or do any sort of surgery, whether it’s minor, major, or in between, we always include the off-chance that there might be a little infection. But those are so rare and uncommon that they don’t really factor into the overall experience. 

Jamie DePolo: So we talked about the risks, now what about the benefits? I’ve read and been told that there are quite a few benefits. Could you just talk about a few of them, maybe what you see as the biggest? 

Dr. Frank DellaCroce: I think the biggest benefit is completing everything. Seeing all the work that’s gone into the reconstruction produces a sense of wholeness, a sense of visual integrity, a sense of healing, and being just complete in terms of the overall process, and closing the loop on the breast cancer and the reconstruction. I think that is a great part of the benefit. 

One other aspect of nipple reconstruction that can be understated, and perhaps maybe even not overstated, is the benefit that comes from creating that central focal point in the overall breast reconstruction that then gives the eye a natural tendency to lose peripheral scars. It tends to reduce their prominence, to almost help them fade by giving the focal point back to the breast.

I liken it sometimes — this is really sort of an odd analogy, but it is true, our minds’ eye, our eyes are drawn towards appreciating our physical being in certain ways. And so a face without a nose wouldn’t be a complete face, and a breast sometimes without a nipple tends to let the eye wander into the perimeter to see small scars that may still be there. So the idea of a newly reconstructed nipple taking precedence over surrounding background scars, if any, is an important part of what I think adds beauty to the result once the nipple is completed. 

Beyond that, just a sense of feeling like the marks left behind from the breast cancer or the prophylactic mastectomy as the case may be have been reduced and that there’s an opportunity now to go forward and be beautiful and be whole and enjoy all the rest of the things that life has in store for them. 

Jamie DePolo: Thank you so much.

Dr. Frank DellaCroce: Thank you, Jamie.

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